Epidemiology and Related Risk Factors of Preterm Labor as an obstetrics emergency

Introduction: Preterm birth is still a major health problem throughout the world, which results in 75% of neonatal mortality. Preterm labor not only inflicts financial and emotional distress, it may also lead to permanent disability. The present study was conducted to determine the related risk factors and preventive measures of preterm labor. Methods: This retrospective cross-sectional study assessed all preterm labors, as well as an equal number of term labors, during seven years, at an educational hospital. Probable risk factors of preterm labor were collected using medical profiles of participants by the aid of a pre-designed checklist. Significant related factors of preterm labor were used for multivariate logistic regression analysis with SPSS 21.0. Result: 810 cases with the mean age of 28.33 ± 6.1 years were evaluated (48.7% preterm). Multipartite; fetal anomaly; prenatal care; smoking; not consuming folic acid and iron supplements; in vitro fertilization; history of infertility, caesarian section, trauma, systemic disease, and hypertension; amniotic fluid leak; rupture of membranes; cephalic presentation; vaginal bleeding; placenta decolman; oligohydramnios; pre-eclampsia; chorioamnionitis; uterine abnormalities; cervical insufficiency; intercourse during the previous week; short time since last delivery; and mother’s weight significantly correlated with preterm labor. Conclusion: Based on the results of the present study, intercourse during the previous week, multipartite, short time from last delivery, preeclampsia, fetal anomaly, rupture of membranes, hypertension, and amniotic fluid leak, respectively, were risk factors for preterm labor. On the other hand, iron consumption, cephalic presentation, systematic disease, history of caesarian section, prenatal care, and mother’s weight could be considered as protective factors.


Introduction
P reterm labor is an obstetrics emergency and a threat to population health. 75% of infant mortality is related to preterm labor (1,2). Preterm labor not only inflicts financial and emotional distress on the family, it may also lead to permanent disability (physical or neural damages) in infants. Approximately one-third of preterm labor survivors suffer from severe long-term neurological disabilities, such as cerebral palsy or mental retardation (3). Furthermore, preterm infants carry increased risk of a range of neurodevel-quate (12,13). In Iran incidence of preterm labor was 7.2% in Tehran, 5.5% in Shiraz, and 8.4% in Khorramabad (14)(15)(16). Although in most cases preterm births occur idiopathically, fetal, uterine, and placental factors as well as maternal chronic diseases, can affect preterm birth (17). In the USA, 70% of preterm births were idiopathic and the rest were due to preeclampsia (50%), fetal distress (25%) and abruption (25%) (18). In another study, preterm multifetal pregnancies and hypertension were introduced as the major factors affecting preterm birth (19). In order to determine the incidence and etiologic factors of preterm labor, the present study was conducted on newborns at the obstetrics emergency department of Shohadaye Tajrish Hospital with a view to identifying preventive measures.

Study design and setting
This retrospective cross-sectional study assessed all preterm labors during seven years, from March 2008 until March 2015, at Shohadaye Tajrish Hospital, Tehran, Iran, by normal vaginal delivery or cesarean section, using census method. An equal number of term labors were selected by simple random sampling as the control group. The study protocol was approved by the Ethical Committee of Shahid Beheshti University of Medical Sciences. The researchers adhered to the principles of Helsinki Declaration, as well as confidentiality of patient data and patient rights.

Data gathering
Probable risk factors of preterm labor such as: mother's age, weight, body mass index, and job; type of delivery (natural or caesarian section), baby's sex and weight; apgar score at 1 and 5 minutes; multi-partite; fetal abnormalities;prenatal care; smoking, alcohol, and opium abuse; history of folic acid, metformin, and iron consumption; history of in vitro fertilization, infertility, abortion, preterm delivery, trauma, vaginal bleeding, intra uterine fetal death (IUFD), dental infection, respiratory infection, and caesarian section; amniotic fluid leak; rupture of membranes; cephalic presentation; vaginal infection; placenta decolman; placenta praevia; polyhydramnios; oligohydramnios; urinary tract infection; systemic disease; anemia; hypertension; preeclampsia; eclampsia; chorioamnionitis; uterine abnormalities, cervical insufficiency; placental insufficiency; polycystic ovary; history of intercourse during the previous week; and timefrom last delivery were collected using medical profiles of participants by the aid of a pre-designed checklist. Incomplete patient files were excluded. Short time from last delivery was considered to be 1 year.

Statistical analysis
The data were analyzed with SPSS software version 21.0. Qualitative data were reported as mean ± standard deviation and quantitative ones as frequency and percentage. Frequency of all risk factors were compared between the two groups (preterm and term) using chi square and Fisher's exact tests. Multivariate logistic regression analysis was applied to independent statistically significant factors for developing a predictive model and odds ratio (OR) of each risk factor was calculated. P value under 0.05 was considered significant.

Discussion
Based on the findings of the present study, independent related factors ofpreterm labor were multipartite, fetal anomaly, prenatal care, smoking, not consuming folic acid, not consuming iron supplements, in vitro fertilization, history of infertility, amniotic fluid leak, rupture of membranes, history of caesarian section, cephalic presentation, history of trauma, vaginal bleeding, placenta decolman, oligohydramnios, history of systemic disease, history of hyperten- sion, preeclampsia, chorioamnionitis, uterine abnormalities, cervical insufficiency, intercourse during the previous week, short time since last delivery, and mother's weight. Intercourse during the previous week, multipartite, short time from last delivery, preeclampsia, fetal anomaly, rupture of membranes, hypertension, and amniotic fluid leak, respectively, were risk factors for preterm labor. On the other hand, iron consumption, cephalic presentation, systematic disease, history of caesarian section, prenatal care, and mother's weight could be considered as protective factors. Preterm labor, as mentioned before, is a major obstetric and pediatric challenge because it is a common, persistent, and often devastating condition with considerable medical, economic, emotional, and social impact (20). It is thought to be a syndrome initiated by multiple mechanisms, consisting of infection or inflammation, uteroplacental ischaemia or haemorrhage, uterine overdistension, stress, and other immunologically mediated processes. However, adefined mechanism cannot be established in most cases (21). Despite advancesin understanding risk factors and mechanisms related to preterm labor, the preterm labor rate has risen in most industrialized countries. In the USA, preterm labor rate increased from 9.5% in 1981 to 12.7% in 2005 (22,23). In the present study, low maternal weight has increased the risk of preterm labor, while in retrospective studies, this factor weakly correlated with preterm birth (24)(25)(26). Although most of the term births were via natural delivery and most of the preterm laborsvia caesarian delivery, no significant relationship was found. The mean age of mothers with preterm laborin this study, were the same as mothers with term infants, while the incidence of prematurity in different studies was greater in old mothers (27,28). Several studies have demonstrated that adequate utilization of pre-natal care is accompanied with improved birth weights and lower risk of preterm birth. On the other hand, inadequate pre-natal care is often referred to as a risk factor for poor pregnancy outcomes. In our study, women who had nowell-designed pre-natal care program, were atrisk for preterm labor (29,30). Infections and vaginosis are well-known risk factors for preterm birth. In a study, presence of bacterial vaginosis at 28 weeks gestation was associated with an increased risk of spontaneous preterm birth (31). Nevertheless, these factors were not associated with preterm birth in our study. Antibiotic therapy could either eliminate infections or modify their effects on pregnancy outcome (32)(33)(34). Smoking has been linked to preterm labor, and in this study this factor hadan association with it (35,36). Although sexual activity, particularly intercourse, during pregnancy has been connected to preterm labor, because of direct effects of semen on initiating preterm labor or alteration of vaginal pH, there is evidence that shows sexual activity during pregnancy is not associated with preterm birth. In this study, intercourse during the previous week affected preterm birth (37). High levels of alcohol consumption during pregnancy have obvious adverse effects on fetal development, but in this project there is no consistency between use of alcohol and chance of preterm birth (38). Various studies have suggested lower rates of preterm birth in women taking dietary supplements (39). Dietary supplements taken before, but not after conception, were linked with a reduced rate of preterm birth; however, a placebo-controlled trial of vitamin supplementsin women before conception and 2 months after pregnancy, reported no effect on preterm birth rate (40,41). Our results showed that folic acid and iron consumption significantly decrease the rate of preterm birth. Preterm rupture of fetal membranes leads to 30% of preterm births in industrialized countries. Management, consists of maternal and fetal surveillance for labor, infection, and abruption, and administration    of corticosteroids or antibiotics (42,43). Ruptures of the fetal membranes are remarkably seen in preterm birth. The availability of medical reproductive techniques has increased the number of multiple pregnancies. In addition, multiple pregnancies resulting from reproductive medical treatments are more common in women of advanced maternal age (44). The preterm birth rate for multiple pregnancies stands at 40-60% (45). Multipartite and in vitro fertilization directly correlated with preterm birth. In our study, pre-eclampsia was 72.3% in preterm labor and 27.7% in term labors. In our study, history of chronic hypertension was seen in 59.4% of mothers with preterm labor and 40.6% in mothers with term labor. In other studies the most common maternal disease was hypertension (16). Using the results of this study and similar onesto eliminate the risk factors and reinforcethe protective factors would be helpful in decreasing the rate of preterm labor and its human and social burden. Yet, for accurately determining these factors, studies with better design, such as cohort studies, with proper follow-up period and large study population, are needed. Since the studied hospital is a referral center for these patients, it represents the general population of the country to a great extent. Still, the final decision regarding factors definitely affecting pre-term labor should be made after further studies.

Conclusion
Based on the results of the present study, intercourse during the previous week, multipartite, short time from last delivery, preeclampsia, fetal anomaly, rupture of membranes, hypertension, and amniotic fluid leak, respectively, were risk factors for preterm labor. On the other hand, iron consumption, cephalic presentation, systematic disease, history of caesarian section, prenatal care, and mother's weight could be considered as protective factors.

Acknowledgements
We would like to thank Dr. M Afrakhte, specialist of perinatology, medical staff of emergency department, and the manager of medical recordsunit of Shohadaye Tajrish Hospital who provided help for this study.

Authors Contributions
All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors.

Conflict of Interest
None